Plain Film Chest Radiography-

Technical Factors
 Penetration = degree of under or over-exposure of the film.
On a properly penetrated film, the intervertebral disk spaces
and branching pulmonary vessels should be faintly visible
behind the heart.
 Is the patient turned or Rotated? If so, the heart size cannot
be accurately measured
 Degree of lung expansion-the number of posterior ribs
visualized above the diaphragm should number approximately
10 (8-12 depending on age) on each side. An underinflated
radiograph exaggerates heart size and obscures visualization
of the pulmonary parenchyma.
 Motion unsharpness decreases detail
Trachea
 Heart on the lateral view
 Anterior portion of the heart—
Right ventricle
 Superiorly—ascending and
transverse aorta.
 Posterior border of the heart
 Upper portion—left atrium
(LA)
 inferior portion—left
ventricle (LV)
 IVC—below LV
 Plain Film Radiography
 Heart size on PA chest—method
utilized most commonly
 Cardiothoracic ratio—an adult
heart, whose transverse
cardiac diameter measures
more than half of the greatest
internal diameter of the chest,
is considered enlarged
(radiologically the transverse
diameter is affected greater
than the vertical diameter).
Cardiothoracic Ratio—Pitfalls
 Portable AP vs. PA films
 Depth of respiration—inspiration vs. expiration
 Thoracic deformity—pectus excavatum; in the
elderly
 Pulmonary diseases that depress the diaphragm
(emphysema)
 Abdominal diseases that elevate the diaphragm
(hepatomegaly, ascites, pregnancy)
 Obesity


PA vs. AP Chest
 Less magnification on a PA Chest
radiograph because:
 The heart is closer to the cassette

 X-ray source is 6 ft. from the cassette


 On the other hand, if there
is an abnormal density overlying the heart border but the heart
border can still be seen distinctly through the density, the disease
process is not immediately adjacent to the heart itself.

This
loss of visualization of an expected structure is known as the
silhouette sign.

It is important for two reasons. First, it

implies the presence of a disease process. Second, it can provide
three-dimensional information about a two-dimensional
image.
 THE BORDERS OF A STRUCTURE WILL BE VISUALIZED
ON AN X-RAY FILM ONLY IF THE RADIOGRAPHIC DENSITY
OF THE STRUCTURE IS DIFFERENT THAN THAT OF TISSUES
IMMEDIATELY ADJACENT TO IT.

For example, the left and right heart borders

should be seen on a chest radiograph because the heart, which
is water density, is bordered by the lungs, which are gas density.

If the heart border is not visible, this suggests that there

is a water-density disease process occurring in the lung tissues
immediately adjacent to the heart.
For example, both the right middle lobe and right lower
lobe project to the right of the right heart border. However,
the middle lobe actually touches the part of the heart that
forms this border, while the lower lobe is situated more
posteriorly.
Therefore, if one sees an abnormal opacity beside the
heart in the right lung base and the heart border is not visible,
then the opacity is in the middle lobe.